Mortality Related Factors in Patients with Spontaneous Bacterial Peritonitis

Öz

Spontaneous Bacterial Peritonitis (SBP) is still an important complication of liver cirrhosis with ascites. Although new developments occurred it has a high mortality rate. In order to identify the related factors of mortality in cirrhotics with SBP, we studied 48 patients who fulfilled the accepted diagnostic criteria. All cases were treated with cefotaxime. The resolution rate was 87% in the study group. Eleven patients (22%) died in hospital. The major causes of death were hepatorenal syndrome (HRS) in 4 (36%) and variceal bleeding in 3 (27%). Fifty parameters were studied to find the correlation. Sixteen parameters (urea, bilirubin, MELD score, CTP score, prothrombin time, INR, AST, ALT, PMNL in ascites, systolic and diastolic arterial tension, sepsis, variceal bleeding, changes in mental status, HRS, culture positivity in ascites) were significantly correlated with mortality. Except for bilirubin, INR, AST and PMNL in ascites, the remaining parameters were also found to be predictive in logistic regression analysis. In multivariant analysis, we found that MELD score, INR, ALT, presence of mental change on admission and low mean arterial tension was significantly reduced the resolution of infection. We conclude that mortality in SBP patients mostly depends on the existence of recent variceal bleeding and the degree of liver and renal failure. Strict measures should be taken in cases with variceal bleeding and hepatorenal syndrome.

Anahtar Kelimeler

• Spontaneous Bacterial Peritonitis, Mortality

Spontan Bakteriyel Peritonit Hastalarında Mortalite İle İlişkili Faktörler

Öz

Amaç: Bu retrospektif çalışma, 940 nanometre dalga boyu ile endovenöz lazer ablasyonun etkinlik ve kalıcılığını, Spontan Bakteriyel Peritonit (SBP) asitli sirotik hastalarda halen önemli bir komplikasyondur. Yeni gelişmelere rağmen yüksek mortalite oranlarına sahiptir. SBP\'li sirotik hastaların mortalitesiyle ilişkili faktörleri tanımlamak amacıyla tanı kriterlerini karşılayan 48 hasta çalışıldı. Tüm hastalar cefotaxime ile tedavi edildi. İyileşme oranı %87 idi. Hastane içi ölüm 11 (%22) kişide gerçekleşti. Major ölüm sebepleri 4 hastada (%36) hepatorenal sendrom ve 3 hastada (%27) varisiyel kanamaydı. İlişkinin araştırılması için 50 parametre çalışıldı. On altı parametre (üre, bilirubin, MELD skoru, CTP skoru, protrombin zamanı, INR, AST, ALT, asitte PMNL, sistolik ve diyastolik arteriyel tansiyon, sepsis, varisiyel kanama, mental durumda değişiklik, HRS, asitte kültür pozitifliği) mortalite ile istatistiksel anlamlı ilişki bulundu. Lojistik regresyon analizinde bilirubin, INR, AST ve asitte PMNL dışındaki parametrelerin mortalite için prediktif olduğu saptandı. Multivariant analizde MELD skoru, INR, ALT, başvuruda hastanın bilinç değişikliğinin olması ve ortalama arter basınçlarının düşük olmasının infeksiyon rezolüsyonunu anlamlı derecede azalttığı saptandı. Sonuç olarak SBP\'li hastalarda mortalite çoğunlukla yeni varisiyel kanama ve karaciğer ile böbrek yetersizliği derecesine bağlıdır. Varisiyel kanama ve hepatorenal sendromda sıkı önlemlerin alınması gerekmektedir.

Anahtar Kelimeler

• Spontan Bakteriyel Peritonit, Mortalite

Kaynakça

1. Garcia-Tsao G. Spontaneous bacterial peritonitis. Gastroenterol Clin North Am 1992;21:257-275.
2. Rimola A. Infections in Liver Disease. In: Bircherm J, Benhamou JP, McIntyre N, Rizetto M, Rodés J, eds. Oxfort Textbook of Clinical Hepatology. 2 ed, 1999: 1861-1874.
3. Hoefs JC, Runyon BA. Spontaneous bacterial peritonitis. Dis Mon 1985;31:1-48.
4. Bernard B, Grange JD, Khac EN, et al. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999;29:1655-1661.
5. Rimola A, Soto R, Bory F, et al. Reticuloendothelial system phagocytic activity in cirrhosis and its relation to bacterial infections and prognosis. Hepatology 1984;4:53-58.
6. Such J, Runyon BA. Spontaneous bacterial peritonitis. Clin Infect Dis. 1998; 27:669-74; quiz 675-676.
7. Franca AV, De Souza JB, Silva CM, et
8. Tito L, Rimola A, Gines P, et al. Recurrence of spontaneous bacterial peritonitis in cirrhosis: frequency and predictive factors. Hepatology 1988;8:27-31.

9. Llovet JM, Planas R, Morillas R, et al. Short-term prognosis of cirrhotics with spontaneous bacterial peritonitis: multivariate study. Am J Gastroenterol 1993;88:388-392.
10. Follo A, Llovet JM, Navasa M, et al. Renal impairment after spontaneous bacterial peritonitis in cirrhosis: incidence, clinical course, predictive factors and prognosis. Hepatology 1994;20:1495-1501.
11. Pugh RN, Murray-Lyon IM, Dawson JL, et al. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60:646-649.
12. Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001;33:464- 470.
13. Rimola A, Garcia-Tsao G, Navasa M, et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club. J Hepatol 2000;32:142-153.
14. Runyon BA, Canawati HN, Akriviadis EA. Optimization of ascitic fluid culture technique. Gastroenterology 1988;95:1351- 1355.
15. Pelletier G, Salmon D, Ink O, et al. Culture-negative neutrocytic ascites: a less severe variant of spontaneous bacterial peritonitis. J Hepatol. 1990;10:327-331.
16. Navasa M, Follo A, Llovet JM, et al. Randomized, comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous bacterial peritonitis. Gastroenterology 1996;111:1011-1017.
17. Rimola A, Salmeron JM, Clemente G, et al. Two different dosages of cefotaxime in the treatment of spontaneous bacterial peritonitis in cirrhosis: results of a prospective, randomized, multicenter study. Hepatology 1995;21:674-679.
18. Lipka JM, Zibari GB, Dies DF, et al. Spontaneous bacterial peritonitis in liver failure. Am Surg 1998;64:1155-1157.
19. Altman C, Grange JD, Amiot X, et al. Survival after a first episode of spontaneous bacterial peritonitis. Prognosis of potential candidates for orthotopic liver transplantation. J Gastroenterol Hepatol 1995;10:47-50.
20. Bac DJ. Spontaneous bacterial peritonitis: an indication for liver transplantation? Scand J Gastroenterol Suppl 1996;218:38-42.
21. Toledo C, Salmeron JM, Rimola A, et al. Spontaneous bacterial peritonitis in cirrhosis: predictive factors of infection resolution and survival in patients treated with cefotaxime. Hepatology 1993;17:251-257.
22. Ricart E, Soriano G, Novella MT, et al. Amoxicillin-clavulanic acid versus cefotaxime in the therapy of bacterial infections in cirrhotic patients. J Hepatol 2000;32:596-602.
23. Ruiz-del-Arbol L, Urman J, Fernandez J, et al. Systemic, renal, and hepatic hemodynamic derangement in cirrhotic patients with spontaneous bacterial peritonitis. Hepatology 2003;38:1210-1218.
24. Thanopoulou AC, Koskinas JS, Hadziyannis SJ. Spontaneous bacterial peritonitis (SBP): clinical, laboratory, and prognostic features. A single-center experience. Eur J Intern Med 2002;13:194- 198.
25. Pinzello G, Simonetti RG, Craxi A, et al. Spontaneous bacterial peritonitis: a prospective investigation in predominantly nonalcoholic cirrhotic patients. Hepatology. 1983;3:545-549.
26. Hoefs JC, Canawati HN, Sapico FL, et al. Spontaneous bacterial peritonitis. Hepatology. 1982;2:399-407.
27. Felisart J, Rimola A, Arroyo V, et al. Cefotaxime is more effective than is ampicillin-tobramycin in cirrhotics with severe infections. Hepatology. 1985;5:457-462.
28. Runyon BA. Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis. Gastroenterology 1986;91:1343-1346.
29. Thuluvath PJ, Morss S, Thompson R. Spontaneous bacterial peritonitis—in-hospital mortality, predictors of survival, and health care costs from 1988–1998. Am. J. Gastroenterol.1988; 96: 1232–1236.
30. Weinstein MP, Iannini PB, Stratton CW, et al. Spontaneous bacterial peritonitis. A review of 28 cases with emphasis on improved survival and factors influencing prognosis. Am J Med 1978;64:592-598.
31. Carey WD, Boayke A, Leatherman J. Spontaneous bacterial peritonitis: clinical and laboratory features with reference to hospital- acquired cases. Am J Gastroenterol 1986; 81: 1156-1161.